Bronchoscopic Removal of Foreign Body from Airway Through Tracheotomy Or Tracheostomy

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CASE REPORT

Bronchoscopic removal of foreign body from airway through tracheotomy or tracheostomy

José C. Fraga,1 Alexandra F. Pires,2 Marcia Komlos,2 Elisiane E. Takamatu,3 Luciano G. Camargo,3 Fabio H.Á. Contelli3

Abstract Objective:most foreign bodies in the airway are removed by respiratory endoscopy. Rarely, the removal of the foreign body has to be performed through endoscopic control by tracheotomy or tracheostomy. This article reports three cases of foreign body removal in children performed by tracheal opening. Description: retrospective review of records with report of three cases of children who aspirated foreign bodies into the airway. In the first case, there was rupture of the tracheostomy tube, with aspiration of its distal portion. Endoscopic removal was performed by tracheostomy. The second child aspirated a pen cap. It could not be removed by endoscopy because it would not pass through the subglottic region. Cervical tracheotomy was performed and the foreign body was removed with endoscopic control. In the last case, the foreign body was in the left main bronchus. It was removed by bronchoscopy through tracheostomy opening. All children presented good outcome after the endoscopic procedure. The trachea of the patient submitted to tracheotomy was sutured after the foreign body removal. Tracheostomy was not necessary. In the children with previous tracheostomy, the tube was put back after the foreign body removal. Comments: most foreign bodies in the airway of children can be removed by endoscopy. When the foreign body is too large to pass through the subglottic region, or so sharp that it can injure the airway, the use of tracheotomy or tracheostomy is indicated.

J Pediatr (Rio J) 2003;79(4):369-72: airway foreign body, tracheotomy, bronchoscopy.

1. Associate professor of Pediatric Surgery, Graduate Course, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS); pediatric surgeon at Hospital de Clínicas (HCPA) and Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil. 2. Medicine student, School of Medicine, Universidade Federal do Rio Grande do Sul. 3. Resident physician, Hospital de Clínicas de Porto Alegre. Manuscript received Dec 12 2002, accepted for publication Mar 26 2003.

369 370 Jornal de Pediatria - Vol. 79, Nº4, 2003 Bronchoscopic removal of foreign body... – Fraga JC et alii

Introduction The child was ventilated, and, after ventilation was The majority of foreign bodies (FBs) aspirated into established, a further attempt was made to remove the the airways of children are removed by means of FB. After a third attempt without success, during which respiratory endoscopy, with endoscopic instruments the patient presented severe oxygen desaturation, with introduced through the mouth. However, on rare occasions cardiac arrhythmia, the decision was taken to use an when the FB is too large to pass the subglottic region, or endotracheal tube and perform a tracheotomy. The trachea is sharply pointed and risks perforating the airway, the was exposed with a cervical incision and prepared for removal of the FB may be performed by opening the opening. The tracheal tube was then removed, and the trachea. bronchoscope inserted into the airway once more. Below we report on three clinical cases of children who Endoscopic forceps were used to pull the FB to the aspirated FBs into their airways, in which FB removal was subglottic region. At this point a transverse opening was performed with an endoscopic instrument inserted by made in the trachea, at the third tracheal ring, and the FB tracheostomy or tracheotomy. removed through the tracheotomy with hemostatic forceps. It was a pen lid. After the child’s ventilation had been established, the bronchoscope was removed and nasotracheal intubation put in place. The trachea was Case descriptions closed with separate stitches using PDS 5-0, and next the Case 1 cervical incision was closed by planes. The cervical F.P.P., 6 years old, female, diagnosed with Central opening was closed without tracheostomy tube insertion. Alveolar Hypoventilation Syndrome idiopathic The child remained with the tracheal tube inserted for 3 (“Ondina’s Curse”), having been tracheostomized during days when he was extubated in the Pediatric ICU. He the neonatal period for apnea and requiring prolonged continued to present stridor and mild intercostal retraction mechanical ventilation. While interned in the Intensive for 02 days, improving thereafter. A follow-up 1 month Care Unit she presented sudden respiratory dysfunction after the procedure showed an absence of respiratory after the PVC tracheostomy tube (Portex™) was symptoms and radiography of the thorax revealed both accidentally dislodged. The initial assessment revealed lungs expanded. that the tube had broken at the junction with the horizontal plate used for fixation to the throat, and that the distal Case 3 portion had been aspirated. Radiography of the thorax confirmed that a portion of the tube was located in the C.S., 4 years old, female, carrying a tracheostomy distal trachea. The child underwent respiratory due to severe subglottic stenosis, resulting from prolonged endoscopy, with a rigid bronchoscope introduced through intubation in the past. Consulted the emergency service the tracheostoma and the aspirated portion of the tube because of fever, tachypnea and yellow secretions from was removed. The patient had an excellent post- the tracheostomy. Under examination presented myiasis endoscopic evolution. of the tracheostoma, and radiography of the thorax showed bronchopneumonia. Antibiotics were started, and, under general anesthetic the tracheostoma was cleaned, and Case 2 innumerable larvae were removed. Respiratory endoscopy A.S.J., 8 years old, male, asthmatic, referred to our with a rigid bronchoscope inserted through the hospital due to acute respiratory dysfunction with tracheostoma revealed larvae in the intrathoracic trachea suspicion of having aspirated vomit. Presented severe and a foreign body (a wooden toothpick/cocktail stick) in respiratory difficulties requiring tracheal intubation. On the main left bronchus. The foreign materials were internment presented radiography of the thorax showing removed with endoscopic forceps introduced through atelectasis of the whole right lung. Fibrobronchoscopy the bronchoscope. The child recovered well and was performed at the ICU, by means of the endotracheal tube, later referred to the Child Protection Service (Serviço de revealed an inorganic FB, blue in color and plastic in Proteção da Criança). aspect at the ostium of the main right bronchus. The patient then underwent rigid bronchoscopy at the Outpatients Surgery Unit of the HCPA, under general Discussion anesthetic, with a rigid bronchoscope with 0º optics connected to video equipment. It was observed that the The presence of foreign material within the airways FB completely occluded the main right bronchus. This of children continues to be a significant cause of morbidity was secured with endoscopic forceps and tractioned. The and mortality. In some countries FBs are even the most common cause of accidental death among children less FB came easily as far as the subglottic region, but would 1 not pass this point. As the FB in the trachea obstructed than one year old. breathing and was provoking oxygen desaturation, it was Soon after inspiration of the foreign material, the child pushed into the right bronchus with the bronchoscope. may present intense coughing, wheezing, vomiting, pallor, Bronchoscopic removal of foreign body... – Fraga JC et alii Jornal de Pediatria - Vol. 79, Nº4, 2003 371 cyanosis or brief episodes of apnea. After these initial equipment through the tracheostomy facilitates the removal dramatic manifestations, the clinical status generally of large objects which have been aspirated into the airway. attenuates or even disappears completely. This short interval When the removal of FBs from the airway requires a during which the child does not present overt symptoms can tracheal opening, it is important that two trained teams work give an observer the false impression that the FB may have together: one for the cervical approach, tracheal opening been expelled by the cough or even swallowed. This is why and removal of the FB viewed directly: and the other for the it is important that doctors are always alert to this diagnostic bronchoscopy, to grip the FB and to pull it up to the 2 possibility. tracheotomy region. That these teams act in synchronization The treatment for children who have aspirated FBs is and quickly is fundamental to the removal of the FB and to their endoscopic removal with either rigid or flexible ensure sufficient ventilation of the child. equipment. However, in rare situations, certain materials Reports in the scientific literature describe the necessity cannot be removed by endoscopy, and must be removed of performing a tracheostomy after a tracheotomy for the through an opening in the airway. A revision undertaken by removal of an FB of the airway. However, this is not 3 Marks et al., studying 6,393 patients with FBs in the airway necessarily an absolute indication for tracheostomy, as may showed that when open surgery is indicated for the removal be seen with one of our patients. If it is possible to suture the of the FB, thoracotomy (2.5%) is more commonly required trachea firmly without leakage, it is only necessary to than tracheostomy (2%). Of the 104 patients who needed maintain tracheal intubation for between 2 and 5 days. This tracheostomy, 52 were because of laryngeal edema after is sufficient time to reduce the local edema and allow safe bronchoscopy, 12 as a route for the introduction of a extubation.4 bronchoscope, 11 in order to permit assisted ventilation, Aspiration into the airway or a fragment of a and only 10 to enable the removal of large objects which tracheostomy canola is an uncommon event.6 The first would not pass the subglottic region.3 In 19 patients the case of aspiration of a fractured metallic tracheal cannula indications for tracheostomy were not commented upon.3 It was in 1960;7 and aspiration of part of a PVC canola is important to note that tracheotomy indication for removal (Portex™) by one child was reported by Sood,8 and by of tracheobronchial FBs, as described for one of our patients, three others by Bhatia et al.9 The aspiration described is reported in only 11 cases in the literature,3,4 suggesting here is the third history published in the literature. In all that this is an extremely rare event. Despite our patient cases, as in our patient, the cannula fractured at the union having been described in an earlier international publication,4 between the tube and the horizontal plate used to fix the we judged its inclusion in this series of cases to be important cannula in the throat.6 The authors attribute the breakage since, while rarely necessary, it is important that doctors to prolonged use or to a defect in the connection of the removing FBs from the airways of children be familiarized tracheostomy tube with the external horizontal portion with the possibility of tracheotomy in order that it may be used for cervical fixation. While PVC cannulae (Portex™) performed when necessary. do not have joints at this point, wear makes the fracture As the subglottic region is the narrowest part of the more likely to occur.6 airway of a child, any edema caused by the passage of a We conclude that a minority of child FB aspirations large caliber FB can reduce even further the caliber of this cannot be removed by endoscopy alone, even when area and make it impossible for the FB to pass a second time performed by an experienced surgeon. The concomitant when removed. This is a dramatic moment during the performance of a tracheotomy, or even the use of a performance of an endoscopic procedure, since an FB previously created tracheostoma, is indicated for patients which does not pass the subglottic region completely who have aspirated particularly wide FBs, which do not obstructs the trachea with hypoxemia, bradycardia and pass the subglottic region, sharply pointed FBs whose cardiac arrest resulting. Before this catastrophic event can points lodge in the subglottis or in the vocal cords, or FBs occur it is important that the surgeon pushes the FB with the which impact the subglottic and provoke acute respiratory bronchoscope into one of the main bronchi, in order to obstruction. allow respiration with at least one of the lungs. This is a life- saving maneuver and is indispensable. During removal of a tracheobronchial FB, the removal of such an object through a tracheal opening is indicated References when the FB is overly wide and will not pass the subglottic 1. Black RE, Choi KJ, Syme WC, Johnson DG, Matlak ME. region, as was observed with one of our patients. Other Bronchoscopy removal of aspirated foreign bodies in children. indications for opening the trachea are the removal of Am J Surg 1984;148(6):778-81. sharply pointed FBs whose points lodge in the subglottis or 2. Hughes CA, Baroody FM, Marsh BR. Pediatric tracheobronchial foreign bodies: historical review from the Johns Hopkins Hospital. in the vocal cords and when the FB impacts the subglottic Ann Otol Rhinol Laryngol 1996;105(7):555-61. 3-5 region and provokes an acute obstruction. Furthermore, 3. Marks SC, Marsh BR, Dudgeon DL. Indications for open in patients who have had previous tracheostomies, as in the surgical removal of airway foreign bodies. Ann Otol Rhinol cases reported in this study, the introduction of endoscopic Laryngol 1993;102:690-4. 372 Jornal de Pediatria - Vol. 79, Nº4, 2003 Bronchoscopic removal of foreign body... – Fraga JC et alii

4. Fraga JC, Neto AM, Seitz E, Schopf L. Bronchoscopy and 8. Sood RK. Fractured tracheostomy tube. J Laryngol Otol 1973; tracheotomy removal of bronchial foreign body. J Pediat Surg 87:1033-4. 2002;37(8):1239-40. 9. Bhatia S, Malik MK, Bhatia BP. Fracture of tracheostomy tubes 5. Swensson EE, Rah KH, Kim MC, Brooks JW, Salzberg AM. – report of 3 cases. Indian J Chest Dis Allied Sci 1992;34:111-3. Extraction of large tracheal foreign body through a tracheostomy under bronchoscopic control. Ann Thorac Surg 1985;39(3): Corresponding author: 251-3. José Carlos Fraga 6. Ng DK, Cherk SW, Law AK. Flexible fiberoptic bronchoscopic removal of a fractured synthetic tracheostomy tube in a 3-yeard- Rua Ramiro Barcelos, 2350 - sala 600 (6° andar) old child. Pediatr Pulmonol 2002;34:141-3. CEP 90430-000 – Porto Alegre, RS, Brazil 7. Bassoe HH, Boe J. Broken tracheostomy tube as a foreign body. Tel.: +55 (51) 3316.8232 Lancet 1960;1:1006-1007. E-mail: [email protected]